Utah Surplus Line Submission Form

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UTAH SURPLUS LINE SUBMISSION FORM
6711 South 1300 East
Salt Lake City, Utah 84121
(801) 944-0114 Tel
(801) 944-0116 Fax
The following statement of insurance, written or proposed to be written by non-admitted insurers is hereby
offered for filing, pursuant to the provisions of the Utah Insurance Code and applicable rules of the Utah
.
Insurance Department
Policy Number__________________________________________________________________
Name of Insured_________________________________________________________________
Effective Date_____/_____/____ Expiration Date ___/___/___ Business is: ___ New ___Renewal
FILING SURPLUS LINE AGENCY
PRODUCING AGENT
Agency Name__________________________
Name_________________________________
Mailing Address_________________________
Mailing Address_________________________
______________________________________
______________________________________
Name of Surplus Line Company (
)
must be on Recognized List
Justification for Surplus Lines placement falls into ONE of the following three categories. Check which
applies to this submission and complete as instructed.
PLEASE COMPLETE ONE (1) OF THE FOLLOWING:
The policy provides insurance for a risk category included on the Export List
Code
Category
________
_________________________________________________________
The policy provides coverages that cannot be written with admitted insurers.
(Attach completed “Evidence of Good Faith Effort to Place “ form)
only one
copy
________
The insured is a commercial insured claiming exemption from the good faith
effort to place with admitted insurers. ______ (Attach an Affidavit signed by
the Insured)
________
NOTE:
This form must be SUBMITTED IN DUPLICATE, with one copy of the policy/certificate,
binder, cover note or other evidence of coverage.
Total Premium $_______________________ x .0425 = $________________ Premium Tax
Total Premium $_______________________ x .0015 = $________________ Stamping Fee
IF THIS SUBMISSION IS NOT RECEIVED WITHIN 60 DAYS OF THE EFFECTIVE DATE, A
PENALTY WILL BE CHARGED.
_____________________________________
Surplus Line Producer

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